Modifier 91 and TC

rwessels

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I am having issues getting the Technical component of a second pathology procedure paid. In our dermatology clinic our provider preps and reads our pathology but in some cases he needs to send out the slide for consult. I am having the issue of the second slide prep being denied. I bill the first line with the 88305 and no modifiers since we prepped and read the slide. The second line I bill with the 91 and TC modifier which was suggested to me by another coder to indicate it is a separate slide that we only performed the technical component for. I am being told by the payer this second prep is "included in the global fee" and is denied. I am getting nowhere with this and any suggestions on how to bill this would be appreciated.
 
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88305 with no modifiers becomes a global service/procedure, therefore the second billing 88305-26 will be included in the first line. It is my understanding that codes 88300-88309 include taking the specimen, examination, and reporting. It would be inappropriate to bill a subsequent 88305 if the tissue was not examined, hence the inclusion denial. Also, the level of coding using 88305 indicates a specific amount of work, and in your situation the first slide clearly required more work as it was read and interpreted, not just prepped. Bottom line, 88305 with no modifier defines itself as both the prep and the interpretation. Billing a second 88305-26 is going to deny, because the TC was already performed in the first line.

So 88305 is off limits because there was no interpretation done. Is there another code outside of that code range that you can choose to reflect that only a specimen was taken and prepped? If you can find a comparative code for just the TC component that's the route you'll have to go. No modifier will break that inclusion denial. I think your only options are to bill only 88305 and eat the charges for the second slide, OR, find a separate code that is just for the technical portion and bill that as your second line with a -TC. If it denies, then I'd appeal with documentation stating the specimen was prepped a second time and sent for an outside consult. (Documentation SHOULD support the reason that second slide needed to be taken and sent for an outside opinion, i.e. why is was medically necessary)

As far as the -91 mod in general, here's the info from CMS:
Definition:
- Repeat clinical diagnostic laboratory test
- In the course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results.

Appropriate Usage
To identify a subsequent medically necessary laboratory test on the same day of the same previous laboratory test

Inappropriate Usage
- Used for a rerun of a laboratory test to confirm results
- Due to testing problems for the specimen
- Due to testing problems of the equipment
- When another procedure code describes a series test
- When the procedure code describes a series of test
- For any reason when a normal one time result is required
 

rwessels

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He does read the second slide but also sends it out for consult. His issue is he does not want the patient charged twice so just wanted to charge the TC of the procedure only.
 
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You'd code for the services that were performed at your facility, 88305. Since it was done twice, you may have to bill 88305, 88305-59. (no 26 or TC)

The consulting provider would bill a consultation code ONLY based on what work the consulting provider did.
88321 Consultation and report on referred slides prepared elsewhere (this is probably what will happen in your case)
88323 Consultation and report on referred material requiring preparation of slides (this would be if the consulting provider had to prepare the slide)
88325 Consultation, comprehensive, with review of records and specimens, with report on referred material (this would happen if you sent the specimen AND the complete medical record)
 
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CodingKing

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You'd code for the services that were performed at your facility, 88305. Since it was done twice, you may have to bill 88305, 88305-59. (no 26 or TC)

The consulting provider would bill a consultation code ONLY based on what work the consulting provider did.
88323 Consultation and report on referred slides prepared elsewhere (this is probably what will happen in your case)
88324 Consultation and report on referred material requiring preparation of slides (this would be if the consulting provider had to prepare the slide)
88325 Consultation, comprehensive, with review of records and specimens, with report on referred material (this would happen if you sent the specimen AND the complete medical record)

I don't think you can bill 88305 twice on the same specimen.
 

rwessels

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It is not the same specimen it is two different ones. danskangel313 thank you for your help on this one!
 
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